OCT Results and Treatment Options for High Eye Pressure

Q: OCT Results and Treatment Options for High Eye Pressure

Hello, sir： Thank you for your inquiry. <br>I would like to respond to your questions and provide the following suggestions：<br>1. <br>First, after discontinuing the medication, observe changes in visual fields, fundus, and intraocular pressure. <br>If glaucoma is present, the vi

OCT (Optical Coherence Tomography) for glaucoma?

Hello, Doctor.
I would like to ask the following: My husband is 45 years old and started using Timolol Chauvin 0.50% eye drops (twice daily) on February 21, 2009.
However, last month another doctor mentioned that my husband's fundus is not too bad (Right eye: Cup/Disk Horizontal Ratio: 0.307 & Cup/Disk Vertical Ratio: 0.232; Left eye: Cup/Disk Horizontal Ratio: 0.349 & Cup/Disk Vertical Ratio: 0.381), indicating that it does not appear to be glaucoma but rather ocular hypertension.
The OCT (glaucoma) report states that although the optic nerve is thin, it is for reference only.
Currently, the intraocular pressure with medication is 17-18 mmHg, which suggests ocular hypertension, and the doctor mentioned that we could consider stopping the medication.
However, we have been using the drops for over seven months, and I would like to seek your opinion on the following questions regarding this matter.

1) What are the benefits and risks of stopping the medication?
2) If the visual field and intraocular pressure worsen after stopping the medication, is this only during the initial phase of discontinuation? Once stabilized after stopping the medication, will the deterioration of the visual field and intraocular pressure also stabilize? Will stopping the medication lead to a rebound increase in intraocular pressure to the previous level of 27 mmHg, or could it potentially rise even higher due to prior treatment, causing more damage to the optic nerve? After several months of treatment, will stopping the medication make the previously untreated pressure of 27 mmHg intolerable?
3) If the visual field and intraocular pressure continue to worsen after stopping the medication, will it be more difficult to control with future treatments or require stronger medications? Will this lead to more unstable intraocular pressure in the future? Could stopping the medication result in higher intraocular pressure than before?
4) Are the potential benefits of stopping the medication:
a) Reducing medication side effects, even if intraocular pressure may rise, but ocular hypertensive patients may experience more stable pressure without medication, thus reducing daily fluctuations and potentially delaying the onset of glaucoma?
b) That using medication will inevitably lead to some residual effects on the eyes and deteriorating vision, and may not necessarily slow the progression of glaucoma?
c) That patients with normal visual fields and ocular hypertension may delay the onset of glaucoma compared to those on medication, but poor medication adherence and pressure fluctuations could accelerate glaucoma onset?
5) Does the OCT (glaucoma) report indicating a thin optic nerve (in red) imply that there is already damage to the optic nerve? Is the thickness of the optic nerve mentioned in the OCT (glaucoma) report related to the optic nerve connecting to the brain?
6) If the visual field is normal but the intraocular pressure is abnormal (if within 24 mmHg), when should treatment be initiated? Should treatment be based on visual field loss, or should it prioritize the OCT (glaucoma) report indicating a thin optic nerve?
7) If there is ocular hypertension (around 22-23 mmHg) and the OCT (glaucoma) report indicates a thin optic nerve, but it is unclear whether the pressure caused the thinning, should treatment be initiated or should we just monitor regularly?
8) If the thinning of the optic nerve is not due to ocular pressure but the patient has already been using glaucoma eye drops, what should be done? Will continuing the medication help the thin optic nerve, or could it lead to another pressure issue?
Thank you, Doctor, for your analysis and insights on these eight questions.
I have attached the OCT (glaucoma) report for your reference.
I look forward to your prompt response.
Thank you very much.
OCT (glaucoma) report: My husband, aged 45, had his intraocular pressure checked on February 2, 2009 (left eye 27 mmHg, right eye 28 mmHg) and underwent OCT (GLAUCOMA) examination, which indicated that the optic nerve thickness is somewhat thin (avg.
Thickness: Right eye 86.15, Left eye 93.35).
Both eyes showed thinning in the inferior position (6 o'clock) in the OCT (GLAUCOMA) report, both in the "red" range (values of 73 & 77).
The right eye in the nasal position (2 o'clock) is also in the "yellow" range (value of 52).
The left eye in the nasal position (7 and 8 o'clock) is also in the "yellow" range (values of 46 & 68).
If the visual field is normal, is treatment still necessary, or can we continue to observe? Average values: OD: S=141, N=61, I=90, T=84; OS: S=143, N=57, I=86, T=89.

OD Right Eye Optic Nerve Head Analysis Results:
- Vert.
Integrated Rim Area (vol.): 0.831 mm³
- Horiz.
Integrated Rim Width (Area): 2.097 mm²
- Disk Area: 2.993 mm²
- Cup Area: 0.204 mm²
- Rim Area: 2.789 mm²
- Cup/disk Area Ratio: 0.068
- Cup/Disk Horizontal Ratio: 0.307
- Cup/Disk Vertical Ratio: 0.232
OS Left Eye Optic Nerve Head Analysis Results:
- Vert.
Integrated Rim Area (vol.): 0.655 mm³
- Horiz.
Integrated Rim Width (Area): 1.833 mm²
- Disk Area: 1.771 mm²
- Cup Area: 0.244 mm²
- Rim Area: 1.527 mm²
- Cup/disk Area Ratio: 0.138
- Cup/Disk Horizontal Ratio: 0.349
- Cup/Disk Vertical Ratio: 0.381
OD (N=3) OS (N=3)
Imax/Smax: 0.84 0.83
Smax/Imax: 1.18 1.21
Smax/Tavg: 2.08 1.97
Imag/Tavg: 1.75 1.64
Smax/Navg: 2.88 3.09
Max-Min: 129 140
Smax: 175 176
Imax: 148 146
Savg: 141 143
Iavg: 90 86
Avg.
Thickness: 93.9 93.8
Thank you, Doctor, for your analysis and insights.

Tim tim, 40~49 year old female. Ask Date: 2009/10/15

Dr. Xie Wenzhen reply Ophthalmology

Hello, sir: Thank you for your inquiry.
I would like to respond to your questions and provide the following suggestions:
1.
First, after discontinuing the medication, observe changes in visual fields, fundus, and intraocular pressure.
If glaucoma is present, the visual field may change.
2.
Second, stopping the medication will not necessarily worsen visual fields or intraocular pressure.
After discontinuation, the pressure may be higher than the baseline measured before treatment, but stopping the medication after several months of use does not mean the pressure will revert to the pre-treatment level.
3.
Theoretically, medication should not make intraocular pressure more difficult to control or lead to greater imbalance.
4.
High intraocular pressure suspected not to be glaucoma may indicate that it is due to factors such as corneal thickness or other reasons.
Therefore, whether to continue medication or not, and its effect on glaucoma progression, will depend on other conditions.
5.
It is important to compare the previous and current OCT results for follow-up.
OCT is generally more effective than visual field tests in detecting changes caused by glaucoma, so it should be prioritized, while also considering the visual field report.
6.
If the thinning of the optic nerve is not due to elevated intraocular pressure, it is advisable to discontinue glaucoma eye drops, as continuing them will not significantly benefit the thinning optic nerve and will not cause additional intraocular pressure issues.
Finally, I wish you peace and happiness.

Reply Date: 2009/10/15

More Info

Understanding the results of Optical Coherence Tomography (OCT) and the implications for treatment options for high eye pressure is crucial for managing eye health, especially in the context of glaucoma and ocular hypertension. Your concerns about the OCT findings, eye pressure, and the potential need for medication are valid and warrant careful consideration.

1. Stopping Medication: Pros and Cons
When considering stopping timolol (a beta-blocker used to lower eye pressure), it's essential to weigh the benefits against the risks. The primary benefits of stopping medication may include reducing potential side effects associated with long-term use, such as dry eyes or systemic effects like fatigue or respiratory issues. However, the risks include the possibility of increased eye pressure, which could lead to optic nerve damage if it rises significantly. If your eye pressure returns to pre-treatment levels (e.g., 27 mmHg), it could potentially harm your optic nerve, especially if you already have thinning noted on your OCT.

2. Initial Effects of Stopping Medication
If you stop the medication and experience a rise in eye pressure or visual field deterioration, it may be a temporary effect as your body adjusts. However, if the pressure remains elevated over time, it could indicate a need for re-initiation of treatment, potentially at a higher dosage or with different medications. The concern that stopping medication could lead to higher pressures than before is valid, particularly if the optic nerve has already sustained damage.

3. Long-term Control After Stopping Medication
If you find that your eye pressure and visual fields worsen after stopping medication, it may indicate that your condition is more challenging to manage. In such cases, you might require more aggressive treatment, including stronger medications or even surgical options, to regain control over your eye pressure.

4. Benefits of Stopping Medication
The potential benefits of stopping medication include a reduction in side effects and possibly a more stable eye pressure without the fluctuations that can occur with medication. However, this is contingent on your individual response and the underlying condition of your eyes. If your visual fields remain stable and your eye pressure does not rise significantly, it may be reasonable to consider a watchful waiting approach.

5. Interpreting OCT Results
The OCT results indicating thinning of the nerve fiber layer (NFL) suggest that there may already be some damage to the optic nerve. This does not necessarily mean that the nerve is dead, but it does indicate that there has been some loss of nerve fibers, which can be a precursor to more significant vision loss if not managed appropriately. The thickness of the NFL is indeed related to the health of the optic nerve and can provide insights into the risk of glaucoma progression.

6. When to Initiate Treatment
The decision to initiate treatment in the presence of high eye pressure but normal visual fields can be complex. Generally, treatment is recommended if there is evidence of optic nerve damage (as indicated by OCT) or if the eye pressure is significantly elevated. Regular monitoring is essential, and treatment may be initiated if there are signs of deterioration.

7. Monitoring High Eye Pressure
If your eye pressure is elevated but your visual fields are normal, regular monitoring is crucial. If OCT indicates thinning of the nerve fibers, this may warrant treatment even in the absence of visual field loss. The goal is to prevent future damage to the optic nerve.

8. Continuing Medication with Thin Nerve Fibers
If you have already started treatment with glaucoma medications, it is generally advisable to continue them, especially if there is evidence of nerve fiber thinning. The medications can help manage eye pressure and potentially protect against further damage to the optic nerve. However, if side effects are significant, discussing alternative treatments or medications with your ophthalmologist is essential.

Conclusion
In summary, the management of high eye pressure and the interpretation of OCT results require a nuanced approach. It is crucial to maintain open communication with your ophthalmologist, who can provide personalized recommendations based on your specific situation. Regular monitoring of eye pressure, visual fields, and OCT results will help guide treatment decisions and ensure the best possible outcomes for your eye health.

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